Rotherham Doncaster and South Humber (RDaSH) NHS Trust completed a Trust-wide audit in August 2021 to look at aspects of physical health management in their inpatient units. Good results were achieved in relation to new admissions having completed initial medical examination within 24 hours and consideration being given as to whether the patient had the capacity to make the decision to agree or refuse such an examination. However, inadequate results were achieved in relation to anything more than an examination of appearance, pulse or blood pressure being conducted with a chaperone, and the patient being given the opportunity to state their preferences in relation to the sex of the chaperone. This audit completed the audit cycle by re-auditing the above criteria in Rotherham inpatient units in order to assess ongoing progress against targets following recommendations.

A dip sample of five patients per ward (two Acute Adult, one Rehabilitation, one PICU and two Older Adult wards) was used. Patients who were admitted between 1st July and 30th September 2022 were picked randomly and their electronic records were studied.

Nearly 90% of patients received a physical examination by a doctor within 24 hours of admission. But, whilst these patients undertook an examination that was more than just general observation, blood pressure or pulse, in only 14% of these was it documented that they had a chaperone present. In addition, not a single person was offered the choice to choose the gender of their chaperone.

Just one third of patients had their capacity to agree or decline examination documented. Perhaps unsurprisingly, the Older Adult wards performed better against this criteria.

Rotherham inpatient wards continue to perform well in terms of conducting timely initial physical health examinations. However, we identified there is a clear lack of documentation around documenting whether someone has capacity to consent to their physical examination or not and what gender someone would prefer to chaperone them. Unfortunately, this is a continuing issue.

We have identified an opportunity at the RDaSH Junior Doctor's induction, where the clerking is explained, to intervene and educate around what the Trust expects as standard.

We plan to implement this change and re-audit the above criteria again to see if we can make an improvement.

This clinical audit is aimed at assessing the knowledge, attitude and practices of team members towards compliance regarding information sharing and consenting service users and to create awareness about existing Trust policies and national guidelines, importance of gaining consent for Information Sharing. Consent to share information should be recorded on the appropriate clinical record keeping system and/or paper. Service users also have the right to request that information is not shared – and staff must record these decisions in the clinical record. Team members work with other agencies and at times need to share patient information. Hence, there should be discussion about who information is going to be shared with, and why. A recorded consent is useful in instances when patient data may need to be shared in court.

The 1st cycle of the audit was conducted from 15th of December 2022 to 4th of January 2023. Clients that met the inclusion criteria were checked to see if the form was filled in by the relevant practitioner/ ever filled in. This was done for both the Community Mental Health Team (CMHT) and Memory assessment Services (MAS). A survey with 7 questions was sent out to team members to assess their knowledge of the Trust policy as well as national guidelines on consent on information sharing.

A total of 238 service user records were assessed. 119 each under CMHT and MAS. Combined results of 37% of the 238 services users had consent documented while 63% did not have consent documented. 27% of services users under MAS had consent obtained and documented. 56% of service users under CMHT had consent obtained. 100% of team members that responded to the survey knew to discuss personal and confidential information sharing with patients. 91% of staff knew that the discussion on consent and information sharing should be documented. 23.5% of staff were not aware of trainings on information sharing and 35.3% of staff were unaware of where to document the consent.

Although rare, unrecorded discussion/consent on Information sharing can cause serious implications. This audit highlights the need to create awareness about the importance of recording Information Sharing consent. Possible reasons for results include team members not being aware of where to document in client records, Trust has not properly educated staff on Information sharing and the way to record it in electronic health records and the Concept of implied consent.

Lithium remains the first line mood stabilising therapy recommended by NICE for Bipolar Disorder and an important treatment option for augmentation of the treatment of Depression. Lithium has a strict monitoring requirement due to long term impact on Renal, Thyroid function and risk of toxicity due to a narrow therapeutic range. This Re-Audit aimed to assess improvement in Lithium Blood monitoring in working age adults in Dudley following an initial 2021 audit.

We used the standards set by NICE CG185- Bipolar Disorder Assessment and Management. We agreed a standard of 3 monthly monitoring of lithium levels due to the number of indications for 3 monthly monitoring to ensure safest practice. We also agreed to standards for 6 monthly monitoring of Urea and Electrolytes (U&Es) and Thyroid Function Tests (TFTs). An additional standard was agreed that at every outpatient review Lithium blood results should be reviewed and documented. A sample of 40 patients was gathered from the 8 outpatient sector teams. We used Rio notes system for demographic, diagnosis and clinical information and blood results systems EMIS and ICE for blood results over a period of November 2021- November 2022.

There was a noted minor improvement to compliance with 3 monthly monitoring, overall increasing from 10% to 17.5%, but this result is still poor. The number of patients who had 4 or more Lithium blood tests over the 12 month period was more of a positive increase, to 32.5% from 17.5% in the previous audit cycle. There was also an improvement in the mean number of lithium blood tests per patient from 2.67 to 3.3. For U&Es 90% of patients were monitored 6 monthly while for TFTs 85% of patients were monitored 6 monthly. There was a slight reduction in documentation of blood results at clinic review, reducing to 62.5% from 67.5% in the initial audit.

While the progress is positive, the results are still far below where the trust would like to be. We considered whether frequency of outpatient review, poor awareness of 3 monthly monitoring standards and a lack of formal system to remind or ensure patients are monitored appropriately. It was agreed that measures to ensure compliance such as a lithium blood monitoring clinic may be useful to improve compliance with monitoring.

To demonstrate adherence to national standards for the aetiological investigation of epilepsy in Bromley Community Learning Disability Team (CLDT), Oxleas NHS Foundation Trust. The National Institute for Health and Care Excellence (NICE) and International League Against Epilepsy (ILAE) advise strenuous attempts to identify the aetiology of epilepsy as it often carries significant treatment implications. The ILAE divides aetiology into six categories selected because of their potential therapeutic consequences (structural; genetic; infectious; metabolic; immune; unknown).

Audit standards were derived from NICE and ILAE. The key standard was that 100% of patients should have sufficient aetiological investigation of their epilepsy, including a dysmorphism assessment, neuroimaging, and genomics, as appropriate. The population was defined as all patients open to the Epilepsy Service of Bromley CLDT in December 2021. Data were collected using a secure electronic database between December 2021 and January 2022.

76 patients (52 male, 24 female) were audited, mean age 38 years (range 18-79 years). Learning disability severity included borderline (n=3), mild (n=28), moderate (n=24), severe (n=17) and profound (n=4). Identified aetiologies included structural (42%; n=32), genetic (13%; n=10), and infectious (5%; n=4), with one patient having both genetic and infectious aetiology. Aetiology was unknown in the remaining 41% (n=31) of patients, of which 58% (n=18) had outstanding investigations. In 72% (n=13), there was no apparent reason for investigations to be outstanding. Genomics was the commonest outstanding investigation (70%, n=14), followed by neuroimaging (20%, n=4) and dysmorphism assessment (10%, n=2). In addition, 40% (n=12) of patients were newly eligible for whole genome sequencing – a recent development within 12 months and thus excluded from outstanding investigations.

This audit demonstrates adherence to national standards is below 100%. Where appropriate, patients with outstanding investigations should be approached. Dissemination of findings and an action plan are required before re-audit.

The stopping over-medication of people with a learning disability, autism or both (STOMP) campaign was launched by NHS England in 2016 as part of the Transforming Care programme. It aims to reduce the inappropriate prescribing of psychotropic medication to manage challenging behaviour in the absence of a licenced indication. The current audit aimed to demonstrate adherence to national standards for STOMP within the community learning disability teams (CLDTs) of Oxleas NHS Foundation Trust. Additionally, a secondary aim was to compare current adherence to the previous audit undertaken in 2019.

Audit standards were derived from national guidance by the Royal College of Psychiatrists and the National Institute for Health and Care Excellence. The population was defined as all patients open to a CLDT prescriber (medical or non-medical) between April 2020 - March 2021. A multidisciplinary working group agreed inclusion and exclusion criteria before designing an electronic audit questionnaire. A random sample of 20% of patients from each of the three CLDTs (Bexley, Bromley & Greenwich) was generated. Data were collected between October and November 2021.

The clinical records of 111 patients were reviewed, 86 of whom met inclusion criteria. Of these, 65 patients were taking psychotropic medication and progressed to full auditing. Key findings were: 85% of patients on established psychotropics had a medication review within the previous 6 months, of which 100% were assessed for their response to treatment and 86% were assessed for side effects; 78% of patients had their capacity to consent to treatment documented and, of those lacking capacity, 81% had a best interests decision documented. All but one of these key findings demonstrated an improvement compared to the 2019 audit.

Overall, this 2021 audit demonstrates a substantial improvement since the previous audit in 2019. However, adherence to national standards continues to be below 100%. Dissemination of findings and an updated action plan are indicated before re-audit in 2023.

There is a body of evidence showing the health inequalities faced by people with schizophrenia, with some studies indicating that their life expectancy is approximately 20 years less than that of the general population. The vast majority of patients with schizophrenia require long-term treatment with antipsychotic medications, such as Clozapine. These can lessen disease burden significantly however can be accompanied by adverse effects, including metabolic syndrome. This audit aimed to determine whether the local physical health monitoring guidelines for those on Clozapine are being carried out for long-stay patients in inpatient forensic and rehabilitation psychiatry services in NHS Ayrshire & Arran.

The guideline “National Standard for Monitoring the Physical Health of People Being Treated with Clozapine” was issued by the Scottish Government in 2017. This guideline advises on physical health parameters which benefit from monitoring during Clozapine titration and on-going therapy. This audit reviewed whether the parameters with specified frequencies, such as annual LFT monitoring, were being monitored within the recommended timeframes.

In our group of 18 patients on long-term Clozapine therapy, 10 had undergone a serum fasting blood glucose and 12 had a lipid profile checked in the preceding 6 months. Meanwhile, all 18 had liver function tests done within the last year prior to data collection. All patients had a BMI, heart rate and blood pressure reading documented in the last year, while 12 out of 18 had an ECG carried out in the same time period.

This audit has revealed a mixed picture in terms of the adherence to guidelines for physical health monitoring for our long-stay forensic and rehabilitation patients on Clozapine therapy. A need for more fastidious blood test monitoring within the forensic service has been identified, with a particular focus on the measuring of serum fasting blood glucose and lipid panels. It was noted that a physical health monitoring checklist incorporating the above guidelines had previously been introduced into the rehabilitation ward, and the benefit of this was demonstrated in the 100% adherence they achieved. We have therefore decided to introduce a similar checklist to the forensic wards as our intervention, with a plan to re-audit in 6 months' time.

According to the Home Treatment Accreditation Scheme (HTAS) Standards for Home Treatment and Crisis Resolution Teams, the physical health assessment and medical review are type-1 criteria. These standards must be met for all service users since failure to meet them would constitute a significant threat to patient safety, rights, or dignity. This audit aimed to measure the compliance of the south Cambridgeshire crisis resolution and home treatment team (CRHTT) with the HTAS standards for physical health assessment and medical reviews.

This audit was registered with Audit & Service Evaluation Registration services at the Cambridgeshire and Peterborough NHS foundation trust (CPFT). The necessary permissions to access patient records on the trust's electronic patient record (EPR) system were obtained from appropriate authorities in the CPFT IT department. From August 2021 to July 2022, all referrals to South Cambridgeshire CRHTT were screened for inclusion and exclusion criteria, and clinical records of 77 service users who met these criteria were analysed. The required data were collected on an excel sheet and analysed using descriptive statistics to measure the percentage of service users who satisfied the audit criteria. The audit was conducted between May 2022 and July 2022.

A total of 1232 referrals were screened, and 77 (6.25 %) service users (n=77) satisfied the inclusion criteria. The average age of service users was 37, with 54.55% of the subjects being females and 45.45% being males. 70.12% of the CRHTT reviews met the Physical health assessment criteria as set by HTAS while 94.80% of the CRHTT reviews met the medical review criteria set by HTAS. The expectations were 100% of the CRHTT reviews should meet the HTAS standards for physical health assessment and medical review. The HTAS standards were not met in 30 percent of service users for the physical health assessment criteria and in 5% of service users for the medical review criteria for the CRHTT assessments done by the south Cambridgeshire CRHTT team for the period between August 2021 and July 2022.

This audit suggests that the south Cambridgeshire CRHTT is currently not meeting the standards laid down by HTAS and there is room for improvement in the physical health assessment and medical review process. The recommendations were made and additional audits may be necessary to ensure that all service users receive HTAS-compliant care.

Serotonin in platelets has a major role in promoting vasoconstriction and platelet aggregation. Selective serotonin reuptake inhibitors (SSRIs), which are widely used clinically, inhibit the serotonin transporter responsible for serotonin uptake into platelets. This serotonin depletion reduces clot formation, thus increasing bleeding risk. This risk is particularly elevated in older adults who are also more likely to have co-morbid physical health conditions. The Maudsley Guidelines recommend that if SSRIs cannot be avoided in those assessed as high bleeding risk, then gastro-protective proton pump inhibitors (PPIs) should be prescribed. The aim of this full cycle audit was to evaluate all patients in an older adult community health team (OACMHT) to assess how many were prescribed an SSRI and whether PPI cover had been considered in those deemed to be at higher risk of a GI bleed due to either age or concomitant medication use.

All patients open to the OACMHT prescribed an SSRI were identified. Their electronic notes were checked to see if they were either prescribed medications or had comorbidities which increased bleeding risk. Electronic notes were reviewed to assess if bleeding risk had been considered at the time of prescribing SSRI, in addition to whether a PPI had been prescribed.

This was repeated 6 months later following the results being presented to prescribers within the OACMHT.

Patient age ranged from 60 – 101 years. 23% of patients were prescribed SSRI medication. There was an improvement in the proportion of patients on SSRIs prescribed PPIs in the second cycle compared to the first cycle of this audit (64.7% vs 56.5%). We also found that the majority of patients prescribed an SSRI and medications known to increase bleeding risk were prescribed a PPI in both audit cycles. We found only 1 patient in our cohort had bleeding risk explicitly documented in electronic notes.

SSRI use is common within the OACMHT. The majority of patients were prescribed a PPI alongside their SSRI. This improved in the second cycle of this audit. A significant number of those prescribed a PPI had their PPI prescription commenced prior to an SSRI being prescribed which may have artificially inflated our results.

However, a significant proportion of patients prescribed SSRIs were not prescribed PPI cover which is not in line with current Maudsley guidelines. Therefore there is still work to be done in minimising bleeding risk in patients taking an SSRI within the OACMHT.

To assess the degree of compliance for clozapine serum level timing post clozapine dose using synnovis (previously viapath) and maudsley 14th edition guidelines in a medium secure hospital.

Electronic prescribing systems were reviewed on each ward to identify clozapine established patients. Viapaths electronic database was reviewed from 01 May 2021 (18 months) and recorded timings were compared to guidelines in Maudsley, 14th edition and synnovis. 12 hours was used as the guideline post dose in OD (once daily), BD (twice daily)/TDS (three times daily) regimes following the night time or evening dose.

4 different types of clozapine prescribing regimes were identified – OD, BD am/nocte or evening, BD pm/night or evening and TDS. 45 patients in total.

OD 12 - most recent bloods 8/12 patients were >15 hours. Total samples in 18 months >12 hours 63.6% (38/55). Total samples in 18 months >15 hours 56.3% (31/55). In the OD group 26 samples are from 2 patients both of whom have samples taken later than 14 hours.

BD 26 - BD mane evening/nocte - 2/5 most recent samples were >15 hours. Total samples in 18 months >12 hours 51.6% (32/62). Total samples in 18 months >15 hours 12.9%(9/62). Need to consider – evening dose time 18:00 compared to 22:00 adding more time.

BD pm evening/night 5 - 2/5 patients > 15 hours. 4/5 patients not at 13-14 hours. Total samples in 18 months >12 hours 75% (9/12). Total samples in 18 months >15 hours 25% (3/12)

TDS 2 - 0 patient > 15 hours, 1 patient at 14 hours. Total samples at 18 months >12 hours - 41.7% (5/12). Total samples at 18 months >15 hours - 16.7% (2/12).

Higher than expected clozapine serum level timing inaccuracy was demonstrated, markedly in bespoke regimes - OD (56.3%) or BD pm evening/night regimes (25%) compared to traditional regimes (TDS 16.7 %, BD am nocte/evening 12.9%). Contributing factors are a knowledge gap amongst services, Maudsley guidelines don't consider bespoke timings when advising trough levels. Findings suggest bespoke regimes need greater consideration when assessing clozapine serum levels.

Action from this initial audit involves informing teams regarding recent samples which are >15 hours post dose. Service education highlighting safety concerns of potential underestimation of clozapine serum level. Guideline change with support from pharmacy. Re audit in 12 months.

People who have a serious mental illness have a higher prevalence of physical health problems as compared to the general population; with a 2–3 times greater risk of cardiovascular morbidity and mortality, double the risk of obesity and diabetes, three times the risk of hypertension and metabolic syndrome and five times the risk of dyslipidaemia than the general population. There is a concern that some antipsychotic drugs have metabolic consequences that contribute to the risk. As such, it is imperative that patients treated with antipsychotics receive appropriate health monitoring. Physical health monitoring of antipsychotic medications is an essential aspect of our practice, and despite assurance in previous audits, we agreed to monitor biannually to ensure we were maintaining standards. Additionally, this audit aimed to look more closely at special monitoring requirements for drugs such as Olanzapine, Chlorpromazine, Clozapine and Quetiapine which had not been measured in previous audits and would likely highlight some areas for improvement.

Audit standards were drawn from the Maudsley Prescribing Guidelines in Psychiatry 14th edition, in addition to NICE Guidance CG178 - Psychosis and schizophrenia in adults: prevention and management.

A random number generator was used to select patients from each of the 7 wards, giving a sample size of 21 patients. Data were collected on Weight, BP, ECG and various blood tests conducted from February 2021 – February 2022. Data was collected from a combination of patient electronic record, CPA reports, and online blood results system. Data were inputted to MS Excel which created percentage compliance in each domain.

1. 1. Blood Pressure: General compliance in the taking of BP met our standard of 100%

2. 2. Weight: Annual monitoring compliance was 93% however compliance fell short for special recommendations for Clozapine, Olanzapine and Chlorpromazine.

3. 3. ECG: Our compliance fell short in the recording of an ECG on admission, or at reaching target medication dose. Annual monitoring compliance was 93%.

4. 4. Bloods: Annual compliance for FBC, LFT, U&Es, Lipids, Prolactin and

5. 5. Glucose were 100%, however our compliance fell short for baseline recording and interim 3-6 monthly monitoring for various blood tests.

Overall results demonstrate good, safe practice, particularly during a challenging period for clinical teams. Shortfalls particularly at baseline were related to risk issues making investigations impractical. It was agreed that there should be an increased frequency of regular glucose monitoring and that HbA1c monitoring was a reasonable measure for this.

Women aged 45 to 55 years can suffer psychological symptoms during the menopause including low mood, increased anxiety and poor memory. NICE guidelines recommend that hormonal replacement therapy (HRT) is considered to alleviate low mood symptoms that arises as a result of the menopause. It is not currently routine for perimenopausal symptoms to be explored during consultations and physical health checks with female patients in the community. Additionally, in secondary mental health settings the option of HRT is not routinely discussed. The aims of my completed initial audit are to improve the psychological symptoms in women experiencing the menopause or perimenopause. I aim to encourage doctors and nurses to routinely screen for perimenopausal symptoms of women aged 45 to 55 years. I aim to encourage doctors and nurses to routinely ask if women in this age category have used HRT or would consider discussing HRT options with their GP.

I performed retrospective data collection of 30 women aged 45 to 55 years in an Outpatient Clinic setting. I referred to the clinic letters of these women over the past 12 months and recorded if there was any documentation of HRT or perimenopausal symptoms. I used the progress note search feature to screen for any further documentation of the discussion of HRT or perimenopausal symptoms. I referred to the most recent completed PHIT (physical health) questionnaire for these women. I recorded if the sexual health section of the PHIT questionnaire had been completed and if any discussion of HRT or perimenopausal symptoms had been documented.

I found that 3 out of the 30 women had discussions regarding HRT and/or perimenopausal symptoms documented in their clinic letter or progress notes. I found that 17 out of the 30 women had the sexual health section of their PHIT questionnaire completed in full. I found that 0 out of the 30 women had documentation of the discussion of HRT or perimenopausal symptoms in their PHIT questionnaire.

My results displayed that only a small percentage of women aged 45 to 55 years are having discussions in secondary mental health setting regarding HRT and perimenopausal symptoms. Therefore, there is a clear need for the further education and training on the menopause for doctors and nurses working in these settings. This will encourage the routine screening of perimenopausal symptoms in women of this age category so that HRT can be considered.

The Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) seclusion policy states that if a patient has been nursed in seclusion for 8 consecutive hours (or 12 hours intermittently over a 48 hour period), then an independent seclusion review (ISR) is mandated. One member of this ISR team must include an Approved Clinician (AC). Our aim was to establish whether an AC (including non-medical) was present at ISRs. If the doctor was not an AC, we established whether a discussion with an AC was documented.

The method included reviewing all episodes of seclusion that took place in CNTW between the 01.10.2021 and the 31.12.2021 (i.e. Q4 for 2021). All electronic (RiO) seclusion records and progress notes were examined to determine who was present at each ISR occurring within each episode of seclusion.

260 episodes of seclusion occurred in Q4 2021 within CNTW. 96 episodes continued long enough to trigger an ISR.

Of the 96 episodes, a total of 221 ISRs were examined.

Of those senior clinicians present at ISR, 83% were medical members of staff, 11% were non-medical ACs and 6% were neither.

Of the medical clinicians present at ISR, 68% were not AC grade.

Of the different grades of non-AC doctors present at ISRs, 72% were "SHO grade".

The overall breakdown of non AC medical staff included 6% F2 Doctors, 16% Higher Trainees, 19% Speciality Doctors, 4% Associate Specialists, 5% were International Fellows and 1% Senior Trust Fellows.

29% of ISRs occurred outside of normal working hours.

71% occurred 9:00-17:00 Monday to Friday (excluding Bank Holidays).

0% of non-AC medical ISRs had a documented discussion with the AC.

Nearly a third of IRSs occurred outside of standard (contracted) working hours for doctors.

In addition, the majority of ISRs were completed by non AC doctors. The majority of these doctors were "SHO" level Doctors (including Core Trainees, GP Trainees and Foundation Trainees).

The audit was presented at the CNTW Seclusion Steering Group, with actions including a change to the seclusion policy. This now explicitly states that ISRs must be conducted by an AC “unless in the case of extreme circumstances, and in such cases the review should be discussed with an AC”.

There are additional plans to develop consistent approaches for organising ISRs (to ensure the vast majority happen within normal working hours and with an AC present).

The aim of this re-audit was to analyse current practice following a previous audit of ECG monitoring in patients admitted to the general adult wards at Clock View Hospital in 2020 and determine whether recommendations made from the original audit have improved performance.The objectives of this re-audit were: screen for recording of the admission ECG; ensure clear documentation of the ECG report; identify any reason why the ECG was not performed within 24 hours of admission and identify whether inpatients with an abnormal ECG on admission had any further investigation(s) done.

92 inpatients discharged from the three general adult wards at Clock View Hospital between 1st of January 2022 and 31st of March 2022 was obtained. The same audit tool designed and used in the original audit in 2020 was used for this re-audit. Each inpatient's electronic record was reviewed to determine whether an ECG was performed within 24 hours of admission. In those patients who didn't have an ECG done, the reason why was recorded (if documented) and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was analysed.

Of the 92 inpatients, 57 (62%) had an ECG within 24 hours of admission and 16 (17%) had one done more than 24 hours after admission. 19 (21%) inpatients never had an ECG done at any point during their admission. The reason for not performing an ECG was documented for 32 (91%) of affected inpatients. Of the 73 inpatients who had an ECG done, 16 (22%) had an abnormal ECG, but only nine had further investigation (56% vs 23% in the original audit).

The findings from this re-audit showed that completion of an ECG within 24 hours of admission to the general adult inpatient wards at Clock View Hospital has improved from 52% to 62%. There has been improvement in quality of documentation of ECG reports. There was no documentation of the ECG report in 13% of cases compared to 35% in the original audit. In almost all affected cases, the reason for not performing an ECG was documented. The authors recommend creating an alert on the electronic record system if an ECG is not performed within 24 hours of admission and asking the ECG reporting service to copy the ECG report to the ward clerk and / or Consultant PA to ensure the report is reviewed promptly.

To investigate compliance with British Society of Haematology (BSH) guidelines and NICE clinical summarieson diagnosis and treatment of folate and cobalamin deficiencies in CAMHS Transition service, Oldham.

The standards used were based on BSH guidelines and Nice clinical summaries, with targets for all 100%:

1. 1. Haemoglobin concentration and mean corpuscular volume (MCV) checked at the same time as assay for serum cobalamin and folate.

2. 2. Cobalamin and folate assays should be assessed concurrently due to the close relationship in metabolism.

3. 3. Treatment of established cobalamin deficiency should follow the schedules in the BNF.

4. 4. All patients with anaemia, neuropathy or glossitis, and suspected of having pernicious anaemia, should be tested for anti-IFAB regardless of cobalamin levels.

5. 5. Patients found to have a low serum cobalamin level in the absence of anaemia and who do not have food malabsorption or other causes of deficiency, should be tested for IFAB to clarify whether they have an early/latent presentation of pernicious anaemia.

6. 6. Treatment of folate disorders should follow the schedule in the BNF.

7. 7. We reviewed all open cases to Transition service in Oldham. Their NHS number was checked through the pathology laboratory portal. In addition, notes on Paris electronic system and digital letters were checked to see if results were acknowledged. The initial audit period run from February 2021 to April 2021.The results were shared with the Multidisciplinary Team and an algorithm was created and shared in an attempt to improve the practice. The re-audit run from May 2022 to July 2022. A total of 80 patients were included in the audit and 25 patients in the re-audit. We entered and analysed our data using Microsoft excel.

Compliance levels for the standards for the audit were as following: standard number 1, 2 and 5 were 100%, number 3 and 6 were 0%, and number 4 was not applicable.

Compliance levels for all the standards were 100% for the re-audit.

The results of the initial audit indicate that not all standards were met. However, results of the re-audit indicate all standards were met. It appears implemented changes may have affected the outcome of results. However, as the sample of patient was small might need to repeat this audit cycle in the future to see if the results remain the same.

The physical health protocols are relevant to psychiatric practice and the algorithm can be disseminated for further use.

NICE guidelines recommend that patients started on antidepressants aged 18–25 years are reviewed 1 week after initiating treatment to check response. All other patients should be reviewed within 2 weeks. The audit aimed to evaluate if these guidelines are being met in Primary Care now that most mental health appointments have changed from face to face to telephone consultations post COVID-19.

Notes of 60 patients that had been started on an SSRI across the period of January 2022 – December 2022 at a North West based Primary Care practice were analysed. Time from initial consultation to medication review with a general practitioner (GP) and/or contact with a Mental Health Practitioner (MHP) within the practice were recorded. Consultation notes from MHPs were analysed for reference to tolerability of medication to assess if the patient's new treatment was discussed as part of support appointments.

Median time for initial follow-up of patients aged 18–25 years was 3 weeks demonstrating 8% compliance with NICE guidelines. Median time for initial follow-up for those >25 was 4 weeks, demonstrating 19% compliance with NICE guidelines. Of those that did not receive a follow-up with a GP within the suggested time frame, 20% met with a MHP for support with their condition and had side effects of new medication referenced in the notes. Within 4 weeks, 58% of patients had an appointment with a MHP where medication was mentioned. Median follow-up for anxiety disorders was 4.5 weeks compared to disorders of depression at 4 weeks. Patients new to the SSRI were followed up at a median of 3 weeks compared to 4 weeks for those that had completed a course previously.

Current follow-up of patients at the practice is not compliant with NICE guidelines. A practice meeting will be held to identify improvements to the patient follow-up process and look at the barriers patients face when arranging follow-up appointments. More than half of audited patients met with a MHP for support within 4 weeks of SSRI initiation. This highlights an opportunity to assess patients that are already meeting with practice staff when GPs have been unable to review them within the time frame. A pro-forma will be developed for MHP to utilise to specifically ask about medication. A repeat audit of both GP and MHP appointments will be completed in 6 months.

To ensure psychotropic medication is being prescribed and monitored as per Trust and national guidelines.

The audit included all patients admitted to the low secure female forensic unit at the time of data collection, giving a total of seven patients. Data were collected from medication charts, psychiatric report and clinical notes. The data collection tool looked at Mental Health Act (MHA) status, diagnoses, current psychotropic and physical health medication, documented indications, consent to treatment forms, completed capacity assessment forms, last medication review and recent physical health monitoring. For patients prescribed Clozapine, frequency of blood testing was checked. For patients prescribed Sodium Valproate, completion of annual risk acknowledgement forms was checked.

The following audit standards were met with 100% compliance: "For patients on regular psychotropic medication, there should be clear indications for this on the drug chart." "All patients on combined antipsychotic therapy or High Dose Antipsychotic Therapy should have a care plan in place." "For patients detained under the MHA, appropriate Consent to Treatment forms should be present and up to date." "All patients should have a documented annual health check within the last 12 months." "All patients prescribed psychotropics should have psychotropic blood monitoring within last 12 months."

The compliance for the standard “For patients detained under the MHA, appropriate capacity assessment documented on MHA 58 Assessment of Capacity for Treatment form should be present and uploaded to Carenotes” was 71%.

The compliance for the standard “All female patients of childbearing age prescribed Valproate should have an annual Risk Acknowledgment form completed” was 0%.

There was a good standard of documentation of medication and indications on drug charts. Consent to Treatment forms were up to date for all patients. Semi-sodium Valproate and antipsychotic medication used out of license was within Trust guidance. Sodium Valproate was used off license in three patients. Monthly FBC blood monitoring occurred for patients on Clozapine, with the most recent Clozapine level within the last 12 months. Physical health checks and investigations were carried out annually for all patients. However, it was difficult to locate all results. Areas for improvement included: All investigation reports should be uploaded in the same folders with easily identifiable file names for ease of access. All patients on Valproate should have a completed annual risk acknowledgement form. The audit recommendation was to put in place care plans for all patients prescribed Valproate therapy, including review dates for risk acknowledgement forms.

Mental illness is linked with a higher risk of dangerous driving; e.g. patients with neurotic disorders have 50% more accidents than controls and 10% of drivers involved in accidents have reported feeling suicidal. The Driver and Vehicle Licensing Agency (DVLA) have provided guidance related to fitness to drive for those with mental illness. In this context we intended to study the risk factors associated with psychiatric inpatients related to driving and whether concerns have been documented in clinical reviews.

Case notes of 100 randomly selected psychiatric inpatients in one calendar month were evaluated including: their driving status; concerns regarding driving based on their clinical status (Diagnosis, Medications, Side effects); any clinical advice given and communication with DVLA in the previous one year, were ascertained from electronic records. Missing values were not included in calculation.

The sample consisted of 51 female and 49 male patients (mean age 39.7±13.5 and 39.1±12.7 respectively), with the majority 69% from Caucasian ethnicity; 64% were informal. There was no difference noted in driving status based on ethnicity or legal status on admission.

On admission 33% of patients reported that they were not driving, 12% were driving, 2% refused to answer and in more than half (53%) driving status was not documented. Considering some of the risk factors for driving, persistent alcohol use was noted in 39.8%, drug use in 34.4%, personality disorder 37%, attention deficit hyperactivity disorder or autistic spectrum disorder in 4%, being on medications with side effects that may impair driving 80.8%, having side effects that impair driving 10%, and suicidality 54.5%. Only in a minority of cases were fitness to drive related issues discussed in their last review (3%), in progress notes (1%), or in discharge notes (2%). There was no documentation related to communication with the DVLA for any patients.

The results suggest there is a need to record the driving status of psychiatric inpatients and to discuss driving related concerns when considering mental state, medications and side effects. Information related to driving should be given to patients, and DVLA should be notified as appropriate. This might help in improving safety related to driving by psychiatric patients.

1. 1. To determine if the physical health monitoring of patients in the Eating disorder service is done in line with the recommendations of the National Institute of Clinical Excellence (NICE) guidelines and relevant MEED Guidance on Recognition and Management.

2. 2. To determine if the current local AEDS (Adult eating disorder services) guideline for physical health monitoring of Community patients, including blood tests and ECG is adequate for community patient cohort.

1. 1. For every attendance of patients to the Outpatient Physical health monitoring Clinic (PHMC), it is expected that the physical health monitoring to be offered would include:

   • • Weight

   • • Height (if first attendance)

   • • BMI

   • • HR (Pulse rate)

   • • Sitting/Standing BP and

   • • Temperature

2. 2. Relevant Blood tests and recent ECGs on a schedule based on patient's BMI or as needed based on clinical indication.

24 patients were identified from April 2021 to December 2022. 7 patients were deemed inappropriate due to scant documentation. Of the remaining 17, 9 patients were randomly selected. 9 patients’ documentation were looked at all contacts with AEDS. The monitoring was audited at 3 single point of contact over the course of their first clinic appointment after April 2021, the middle and latest/last monitoring.

1. 1. At the first clinic after April 2021 the compliance was 100% for all parameters except for the monitoring of BMI and Temperature which was 88.9%.

2. 2. At the mid-point there was 100% compliance with BMI, weight, blood pressure and pulse monitoring, there was a drop in temperature monitoring to 77.8%.

3. 3. In the last clinic monitoring for pulse and temperature dropped to 88.9% and 77.8% respectively, all other parameters showed 100% compliance.

4. 4. The frequency of monitoring ECG and blood tests in the subsequent clinics gradually dropped from 100% to 66.7% and 88.9%.

Reasons for decreased monitoring in Bloods and ECG.

1. 1. Documentation was missing.

2. 2. Investigations were delayed from the patient's side.

3. 3. Due to COVID-19 there was difficulty accessing the primary care appointments for investigations.

4. 4. The temperature equipment was not working properly.

1. 1. Keeping a fixed format for documenting PHMC. New format for documentation introduced.

2. 2. Document all the parameters checked in the patients’ electronic records on the same day.

3. 3. PHMC clinical team to upskill on ECG via training.

4. 4. Introduce weekly ECG alongside phlebotomy clinics.

5. 5. SUSS test to be done for all RED (High risk) patients and should be clearly documented in the notes.

The Royal College of Psychiatrists (RCPsych) has formulated “Attention Deficit-Hyperactive Disorder (ADHD) in Adults: Good Practice Guidelines” to provide evidence-based guidance for clinicians, acknowledging there is an increasing burden on the services with the assessment and management of adult ADHD in the United Kingdom. As there is no trust-wide policy in North Wales and some practitioners perceive that it is challenging to perform an extensive assessment for ADHD in the adult secondary mental health services, there is a need to study the pre-referral workup and diagnostic approach for patients referred to the adult mental health services. This clinical audit is aimed at understanding the guideline adherence level of the assessment and management of adult ADHD by both primary and secondary mental health services in Betsi Cadwaladr University Health Board.

Convenient sampling was performed on 50 patients from three community mental health teams (CMHT) from East of North Wales for patients with a confirmed diagnosis of adult ADHD. The source of information included referrals from the primary care (including general practitioners and primary mental health service) and medical records from the secondary mental health care. Relevant clinical information was collected and coded as “present”, “absent”, or “unclear”. The data were compared to the standard derived from “ADHD in adults: Good practice guidelines”.

Only 34% of the referrals documented the use of Adult ADHD Self-Report Scale, 18% documented the use of Autism Spectrum Quotient (AQ-10), and none documented the use of Weiss Functional Impairment Rating Scale (W-FIRS).

Only 46% of patients was diagnosed using a standardised instrument after more than one session of diagnostic assessment. The percentage of documentation of baseline blood pressure, pulse rate, weight, and height were 58%, 70%, 50%, and 44% respectively.

Most documentations fell below 50%, including comorbid and family history of physical health conditions, history of neurodevelopmental issues, and corroborative history. All teams performed well with the documentation of functional impairment, comorbid anxiety disorder, depressive disorder, and substance use disorder, i.e., >90% of patients.

This audit reflects the need for quality improvement in documentation in both primary and secondary care settings although the solution should not add to the existing burden of practitioners. Convenient sampling from East of North Wales limits the generalisability of findings. Also, the absence of data may be contributed by logistic issues around paper-based medical records, i.e., illegible handwriting and inability to locate the documentation.

ADHD diagnoses have skyrocketed in the recent times resulting in a lot of the patients being on stimulant medications. NICE guidelines recommends a baseline review of physical health which should include height, weight ,baseline pulse and blood pressure and a cardiovascular assessment before starting these medications. It also recommends 6 monthly monitoring of weight, blood pressure and pulse. We aimed to assess the current practice of baseline and 6 monthly physical health monitoring against the standards set by NICE guidelines.

33 random case notes were identified from the adult CMHT who had a diagnosis of ADHD and were receiving stimulant medications. An audit pro-forma was designed to collect data on baseline blood pressure, pulse, weight ,cardiovascular assessment before commencing treatment and 6 monthly monitoring of Blood pressure, Pulse and weight. The data were collected over a period of 3 months between October 2022 and December 2022.The results were presented in the local CMHT meeting and a new proforma was designed for baseline and follow-up physical health assessment which will be incorporated in the case notes. A re-audit is planned in March 2023.

There were 16 females and 17 males in the identified cases.19 patients were on different Methylphenidate formulations,8 patients were on Lisdexamfetamine and 6 were on Atomoxetine.19 patients (57%) had documentation of baseline blood pressure, 13 patients (39%) had documentation of baseline pulse,17 patients (51%) had documentation baseline weight and 2 patients (6%) had documented baseline cardiovascular assessment in the case notes.10 out 33 patients had 6 month follow-up visits and monitoring data were collected from them. None of the patients (0%) had documentation of blood pressure, pulse or weight in the case notes.

The adherence to NICE guidelines was low in physical health monitoring as hypothesized by the team. A new proforma for baseline and 6 monthly physical health monitoring is developed by the audit team which is aimed to increase awareness about the physical health monitoring amongst the clinicians. The need for improving this practice is crucial due to increasing number of patients on these medications and the risk of serious side effects.